Archive for February, 2010

Many of the people I work with as a psychotherapist have been very seriously impacted by their life histories.They did not ask for this. It’s like a rock that falls out of the sky, striking them for no discernible  reason. It’s our task to go forward and make their lives work better. Sometimes rather simple tools yield powerful results, as I relate here.

The problem: getting control of intrusive symptoms

Many of my clients have Post-traumatic Stress Disorder. This is usually quite treatable, but success in treatment often isn’t simple. Sometimes I’m faced with a client whose symptoms interrupt their life so much that it makes ongoing treatment difficult if not impossible. This is (obviously) a show-stopper. We simply must moderate the impact of those symptoms if we are to get treatment launched (which will, of course, we expect to make the symptoms go away).

An example: I have a client whose depression, social isolation, high degree of distractibility, and intermittent flashbacks all result in their having real difficulties in remembering appointments, much less actually showing up for them. Symptoms of their disorder are effectively blocking treatment, so we must achieve real symptom management if we’re to accomplish anything significant.

The intervention: tracking symptom intrusion events

So, we recently started formally tracking commitments he makes – for phone calls with me (in which I do brief counseling), as well as psychotherapy appointments. We use an online Google Docs spreadsheet to track both individual commitments he makes AND, should he fail to keep a commitment, the disruptive symptom(s) which impacted him and caused the problem. The purpose of this is help us both focus on identifying and improving management of specific symptoms which are making his life dysfunctional. To both of us, this direct, straightforward, utilitarian approach appears to be working.

It’s about behavior change, not moral re-tooling

There’s also an important implicit message being conveyed here: when you don’t keep a promise, there’s a reason. Something’s happening in your brain which is not serving you well. It’s not about moral failure, or flawed character, or anything remotely related to that outdated, conceptually limited, seventeenth century way of thinking about human behavior. It’s just a programming glitch, pure and simple. We need to isolate the “bug” in the brain program, and fix it. Since we cannot directly access the program, we go at it indirectly, using known psychological principles[1]. This is indirect access is not ideal, but it’s the only access we have, and its good enough – it will get the job done.

So, looking at my client who has trouble keeping promises, we are not going to do a moral analysis of the situation. We’re going to use our best knowledge to make sense of it, and to change what’s happening. Since we understand (I hope – see note 1 below) that a psychological principle CANNOT be Mosaic (absolute or deterministic)  in nature, just what IS it? It’s a pragmatic description of what is likely to happen in a situation, to the best of our knowledge. It’s a probability statement, a kind of “bet”, if you will.

Watched pots boil faster – how the eyes of a group can help an individual

The key psychological principle on exhibit here is social facilitation.[2] It has been noted in psychology, for over 100 years, that people perform better when observed. Modern updates on this note that this is true, generally, with simple behaviors, but can be quite the opposite with complex behaviors.

What I’m trying to do with my client is increase his sense of being observed, both by me and by him (but not by anyone else, as the Google Docs spreadsheet is not accessible to the public), with the expectation that the mere fact of increased observation will improve BOTH his and my management of his intrusive symptoms.

For every intrusive symptom we’ve identified, I’ve suggested to him (IN the online spreadsheet) a simple cognitive-behavioral management intervention. Because the interventions are simple, they ought to be better utilized when his sense of being observed increases. It’s a reasonable bet. Whether the bet pays off or not will be tracked in the spreadsheet. Both he and I contribute to the spreadsheet. His participation is critical. It’s visible manifestation of his very real motivation to get his life in order. He defaulted on a promise last night, and he himself entered that fact into the spreadsheet (it was his first such default, by the way, since we started spreadsheet tracking).

So, this shared spreadsheet functionality make it possible for him to be more visible to himself, and we’re already seeing improved results – dramatically so. Awareness tends to confer increased choice (another practical psychological principle). Because his behavior is improving, his hope for real change in his life is growing. It’s all a simple thing to do, but has already had a  large effect on his life.

An event in progress

We are early in this intervention effort. It may yet fail, even if it surely hasn’t so far. If it does, we’ll simply assess the situation, redesign interventions, re-engage, and continue tracking outcomes.

Today, however, I’m totally pleased with our results. Our use of the Internet as a private computer network may be a little unusual, but…it’s working. and that’s no small thing – not to my client, and certainly not to me. I like to win. We’re winning.


1. I need to explain what I mean by “known psychological principles”. I am NOT referring to  “principles” that are Mosaic in nature (i.e., those which have the authority of Moses, of “Ten Commandments” fame). While the existence of such principles have long been asserted, to assert is not to validate. Saying that, I must clarify that in our times truth is NOT validated by reference to authority, but by demonstration in the real world. Obviously, not everyone accepts this, but the scientific psychology/psychotherapy community does, and it is from that point of which which I write.

In the nineteenth century, our best thinkers thought we’d finally located  principles of at least near-Mosaic quality –  in the magnificent Newtonian universe of mathematically describable mechanics and thermodynamics. But, with the emergence of Einstein’s relativity and quantum physics (with which Einstein never made his peace), that all fell apart. This new world-view, essentially in place by the early 20th century, is with us still.

Educated people now generally now that we live in a world imbued with uncertainty (probability), not principles (determinism) of the old sort. “Principles” exist only in the simplicity of casual speech and informal thought, the real world does not appear to offer such principles. One can certainly assert the existence of a “principle”. That’s easy enough. It’s demonstrating its validity – its truth – that always proves surpassingly difficult.

People who exuberantly talk about their “principles” and their “values” as if their veracity were beyond doubt are exhibiting intellectual dishonesty. They give us the conclusion of an argument (thought process), but not the argument itself. It’s as if I said, “I’m simply going to believe that what Newton described to us his Principia is true. Because I trust this document, I know that the world is inherently mechanical, because the Principia says so! Mechanistic determinism is true, else Newton wouldn’t have devoted so many pages to its description!” As a medieval philosopher might dryly say, “non sequitor” – nonsense.

The question here is not whether a mechanical view of the universe is good and true, but whether the assumption that Newton got it right in his Principia is supported (and it is not, in the argument I give here). The “values” crowd invariably makes a gratuitous assumption sabout some source document or idea, then deductively derive propositions from that assumption. It’s child’s play, and we’re not going to do that with real people in the real world. What we think has consequences, so we’d better get it as right as we possibly can – demonstrably right.

2. The referenced article is brief, but well summarizes the concept.

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I just had an email exchange with a junior at a local college. Stress is a particular concern with this individual, and they’ve had both major challenges and major successes with stress in recent months. Today, they’re telling me that they are feeling “…a bit under the weather”. My response:

Yeah, used to happen to me a lot, too, in college. Why? Stress, pure and simple. It’s a high stress environment, which is one reason why you’ll be SO happy to be finished with it, eventually! Stress impacts our immune system negatively. Folks in college, where they’re exposed to all known pathogens in the universe (!), must be especially wary of this effect. Sooner or later it’ll “take ya down.”

While working one’s way through the college obstacle course, its wise to take the following recommendations as seriously as you can. I trust their effectiveness highly:

  • At any time need to lower your stress level, do a large sigh, in which you release as much muscle tension as possible. At the end of the sigh, sit in a little mental “quiet spot” for a few moments, being as still as possible internally. Practice not-doing for a few moments. Then return SLOWLY to the task at hand. Focus and move on. Repeat often, as this will train you brain to “settle down” more reflexively.
  • Sleep is the great healer. It “…knits up the raveled sleeve of care” – that’s how Shakespeare puts it. So, sleep MORE than you think you need. It’s putting money in the bank. Nap as often as you feel the need, and AT LEAST ONCE DAILY, preferably for 90 minutes. New research just out reports that people who do this LEARN MORE, recall more, etc., etc. A great payoff for something that also has distinct intrinsic rewards. I try to do this at least once daily. Lately, I’m getting up to 9.5 hours of sleep daily. I feel WAY better. Think I’m on to something? Care to try it yourself???
  • Exercise is the great normalizer, and second only to sleep (and proper eating) as a source of stress relief. By exercise I mean either aerobic (walking briskly or running or swimming, etc.) or resistance (weight room work or equivalent) exercise. Both give you simple tasks to do (“simple” is good), and an opportunity for a mental break. Probably more importantly, both cause fatigue in the large muscles of your body. Fatigued muscles relax, and relaxed muscles actually cause negative feelings in the brain to shut down. That’s stress relief of the most fundamental sort. But wait – there’s more: real exercise induces good, deep, healthy sleep. In college, when I started exercising right after finals, I stopped getting sick (which, until then, was highly likely).
  • Mind your mind: Remember your successes. You have many. You’ll have more. They’re what you’re working for. To get them, you MUST have some failures as well. Welcome then. They teach you what does NOT work – essential knowledge, and what you cannot (yet) do. If you’re not failing some of the time, you’re playing it safe or being lazy. So, work to accumulate those necessary failures, and the successes will come as sure as tomorrow’s sunrise.

For years, my own recipe for recovery or self-rescue from periods of intense stress has been very simple and quite fool-proof: eat, exercise, sleep. It simply always works.

Worth a try, eh?

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Since about November, 2008, I have been slowly working to improve the Posttraumatic stress disorder article at WikiPedia. It’s been fun, though at times inordinately time-intensive. Much of the article awaits my planned revisions, and I’m the only MHP (mental health professional) working on it, at the moment. As far as I can tell, I’m the only one who ever has. (More about that later…)

A few of the article’s sections are looking rather good. Medication (which took me 3 days!) is great, and Epidemiology is about 90% there. Other sections aren’t bad, but lack adequate references, or need their references checked (people can be incredibly sloppy). Some need a complete rewrite. Overall, the whole article needs some basic reorganization, which it’s about to get.

Wikipedia has enormous exposure on the Internet. It’s among the top 5 most-visited sites on the Internet. Of those, it’s the only one that’s non-profit. Its influence on a large segment of Internet users and various organizations and publications is truly impressive, and well surveyed here.

It’s also enormous. Nine years old, it currently has 14 million articles. Not words. Articles. Whew. Someone has a lot of free time, yes? In truth, I think it’s more about the passions of a small group of individuals, and the desire to share, than about free time.

It’s written collaboratively. You can go write there, if you like, but…you’ll have company. You’ll have to learn to work cooperatively, and to take the time to learn a little of the culture. There definitely are some rules and traditions you’re expected to play along with. Pretty much all good stuff, to be sure, but with some particulars you do need to know.

A certain amount of it appears overly influenced by popular culture, and an almost (heck – distinctly, at times!) adolescent point of view. But, for all that, there are reams of articles there which are very carefully written, meticulously documented, and flagrantly informative, if I may put it that way. A recently published study found its accuracy compared quite well with that of the Encyclopedia Britannica.[1]

When needing some quick information about some serious topic, Wikipedia is often the first place I turn. If nothing else, the references and links at the end of an article will quickly point me to some excellent information sources. But I usually get  much more than that.

Still, quality varies broadly, so it’s best that you know a little about your subject before reading a Wikipedia article, so you can filter the rocks out of the humus.

So, when I found that one of my clients with PTSD was reading about it there, I reviewed the article, and I was both intrigued and bothered. Some material in the article was excellent, but other major parts were poorly written, dubiously sourced (i.e., using shabby references), or simply irrelevant. I was annoyed. After some thought, I decided to try to fix it. But…I was totally new to Wikipedia, so I started slowly.

I hung out at the article’s Talk page for a while, and wrote some rather long and detailed answers to various questions. Suitably warmed up, I began contributing to the article itself. Slowly it dawned on me that I basically had no competition. There is only one other health care professional  involved with the article, at times, but he’s not a mental health professional, much less an anxiety disorders specialist. So, as it turns out, as long as I do my work according to accepted conventions (write clearly, make sense, and source major assertions with obvious authoritative references), I’m not challenged.  And, because of Wikipedia’s exposure and influence,  I’m feeling like I’m making a real contribution. At the very least, I can begin to stop worrying about what my clients might be learning about PTSD at Wikipedia!

So why am I so alone, as a major contributor to the article? I can only conjecture. In my personal experience, my MHP peers are a very caring, committed, and somewhat narrowly focused group of folks. Granted, work + family = little free time for many people, but that doesn’t tell the whole story. Many MHPs don’t write much, if anything at all. Many are not exactly enthralled by research-oriented psychotherapy. Few have much interest in community education or outreach issues. So, who’s left? Apparently, not many people at all.

I recently appealed for help on an Internet Discussion list I started some years ago. It has about 200 members, and a number of them are quite serious folks. I got no takers. OK…I guess I’m on my way to being the sole professional source for Wikipedia’s PTSD article. I do hope to have company at some point. It can only work to improve the article. However, I’ll stay with it until it meets my standards, which are definitely demanding. How demanding? Well, my Masters thesis in Counseling Psychology ran 385 pages, and I was told I’d written a dissertation. Didn’t get a Ph.D. for it, though.


1. Jim Giles (December 2005). “Internet encyclopedias go head to head”. Nature 438: 900–901. doi:10.1038/438900a. http://www.nature.com/nature/journal/v438/n7070/full/438900a.html.

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I recently added the following section (notes are at end of the post) to the Posttraumatic stress disorder article at WikiPedia (see my next post, for more on this). The information is completely up to date, and rather interesting – although probably only to other MHPs who treat significant numbers of clients with PTSD, which is my specialty –

Proposed changes to current DSM-IV criteria

(Note: the “DSM” is the Diagnostic and Statistical Manual of the American Psychiatric Association – the compendium of established mental illness diagnoses which mental health professionals in the USA, and a few other places, use. The fifth major revision is in preparation, and will be published soon. It’s a Big Deal, at least for some of us.)

On February 10, 2010, the American Psychiatric Association placed online for comment the draft diagnostic criteria for mental illness diagnoses which are proposed for the upcoming DSM-V. After a public comment period closes on April 20, 2010, the criteria will be field tested for two years, prior to final revisions and publication in May of 2013.[1]

The draft PTSD diagnostic criteria contain some noteworthy changes:[2]

  • Criteria A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual’s emotional response at the time (current criteria A2) is dropped.
  • Several items in Criteria B (intrusion symptoms) are rewritten to add or augment certain distinctions now considered important.
  • Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This is especially evident in the restated Criteria B – intrusion symptoms. Development of age-specific criteria for diagnosis of PTSD is ongoing at this time.
  • Criteria C (avoidance and numbing) has been split into “C” and “D”:
    • Criteria C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in descriptions.
    • New Criteria D focuses on negative alterations in cognition and mood associated with the traumatic event(s), and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in the previous criteria.
  • Criteria E (formerly “D”), which focuses on increased arousal and reactivity, contains one modestly revised, one entirely new, and four unchanged symptoms.
  • Criteria F (formerly “E”) still requires duration of symptoms to have been at least one month.
  • Criteria G (formerly “F”) stipulates symptom impact (“disturbance”) in the same way as before.
  • The “acute” vs “delayed” distinction is dropped; the “delayed” specifier is considered appropriate if clinical symptom onset is no sooner than 6 months after the traumatic event(s).

Finally, the inclusion in the DSM-V of a Developmental Trauma Disorder is still under discussion, at the time of the draft publication.[3]


1. Gever, John (10 February 2010). “DSM-V Draft Promises Big Changes in Some Psychiatric Diagnoses”. http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/18399. Retrieved 10 February 2010.

2. “309.81 Posttraumatic Stress Disorder – proposed revision – rationale”. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#. Retrieved 11 February 2010.

3. “Conditions Proposed by Outside Sources”. http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx. Retrieved 11 February 2010.

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